Lot 15 Septic Application & Permit CHECK OR FILL IN WHERE APPLICABLE
No..:.f._q.Q
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF /HEALTH
6C.:eta- OF nel-C4 471
) pplirntinn fur 3inpnnal
cr
nrk( Cnnn,ttrnrtinn Permit
Application is hereby made for a Permit to Construct (frc or Repair ( ) an Individual Sewage Disposal
System at:
Lomb edd,
Address
„er a Address
Size Lot Sq. feet
Expansion Attic ( ) Garbage Grinder ( )
No of persons Showers ( ) — Cafeteria ( )
Type of Building
Dwelling—No. of Bedrooms
Other—Type of Building
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacityjaSdgallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by Date
Test Pit No. I minutes per inch Depth of Test Pit Depth to ground water
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the hoard of health.
Signe L l,C w. /�l` ../12241-Ofd-1.:� J .�� I' L, o.y
Application Approved Ry ( Ne!- ...�{� k"J; ._._.. - _C -I_y 7 _
as
Application Disapproved for the following reasons-
Permit No....y.ay.R
oath
Issued.......��/....0:SG_-/._��1 1—
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Qlrrtifiratr of Tamplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
Installer
at
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Oispnn$$ arks fltnnstrnrtinn tirrinit
Permission is reby granted.._4_.
to Construct,.( or,Repair ( )fin Individual_ sewage Dispa=al S�$tem
at No 2 yYF:...(R+aass-LR , .
Street �y
as shown on the application for Disposal Works Construction Permit No..yir Dated....,7 Q,.�,.
d of Hta th :
FEE..l..S.x..QIL.
DATE
FORM 1255 HOSBS & WARREN. INC.. PUBLISHERS
CHECK OR FILL IN WHERE APPLICABLE
No
THE COMMONWEALTH OF MASSACHUSETTS
Vita
BOARD OF HEALTH
C/ 7/ OF /14'eilleol-M Tot
Appliratintt for TAinpusat Markle Qlnneftrurtinn Permit
Application is hereby made for a Permit to Construct ( Gror Repair ( ) an Individual Sewage Disposal
System at:
FG nee-A; RD
•L/S
Location-Address or Lot No.
X'e7,w yAtet/e y
Owner Address
Installer
Type of Building
Dwelling—No. of Bedrooms
Other--Type of Building
Other fixtures
Design Flow gallons
Septic Tank--Liquid capacity gallons
Disposal Trench—No Width
Seepage Pit No Diameter
Expansion Attic
No. of persons
Addres
Size Lot-q 2av ± c,• feet
Garbage Grinder ( )
Showers ( ) — Cafeteria ( )
per person per day. Total daily flow gallons.
Length Width Diameter Depth
Total Length Total leaching area sq. ft.
Depth below inlet Total leaching area sq. ft.
Other Distribution box ( ) Dos' tank //
Percolation Test Results Performed by26WtZ encAt<.'.`../ !d;IC€1 £i&& Date.-7- 9-7/
Test Pit No. 1 /.O minutes per inch Depth of Test Pit ?–R's Depth to ground water.Attie:
Test Pit No. 2 minutes per inch Depth of Test Pit('4- d
" Depth to ground water ,'Q r
Description of Soil P 2 " C .6AU,C--.ZCPSzetc. 3`p" Pt f,f.BSSQ.f-C" toe/ L uF Mao1
v
Nature of Repairs or Alterations—Answer when applicable
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed
Application Approved By
Application Disapproved for the following reasons'
Permit No
to
Date
Date
Issued
Date